Men with Borderline Personality Disorder

I met Michael about a year after he and his wife Diane had gone for two counseling sessions following an incident at home. One evening, after they returned from a gathering with friends, Michael accused Diane of flirting with the husband of a woman who was Diane’s best friend. Diane acknowledged that she’d had a few drinks that night, but she was taken aback and denied that she’d been intentionally flirtatious. This was not the first time that Michael had made such accusations. In fact, he had a longstanding habit of accusing Diane of wearing “sexy” clothes when they went out, of flirting with other men, or of exchanging glances with other men when they went out for dinner.

Despite Diane’s denial a fight ensued, which she could not de-escalate. Then, as he made to leave the room Michael pushed Diane. She stumbled backwards, knocking over a table and lamp, and fell to the floor. Michael’s yelling, combined with the racket made by the table and chair and Diane’s fall, woke their two children, who emerged from their bedrooms in tears. Michael then proceeded to stomp around the house, upending a chair and further frightening the kids. He then left, got into his truck, and drove off. At that point, fearing for what might happen next, Diane called her best friend, hastily dressed the children, and spent the night there.

Michael figured out where Diane and the children had gone as soon as he returned to his house to find it empty. He called there, asked to speak to Diane, and apologized profusely. He also agreed, albeit reluctantly, to see a counselor with her again.

Two of the issues that came up in those first counseling sessions were Michael’s drinking and what Diane described as his moodiness. Whereas Diane had cut down severely on her drinking beginning with her first pregnancy, Michael drank two or three cocktails every night, which he justified as providing relief from his stressful job as a financial adviser. But as Diane explained, “If Michael gets into one of his moods, his cocktails only make it worse.”

Men with BPD

Michael suffers from Borderline Personality Disorder, or BPD. Like the vast majority of men with this disorder, however, he has not been diagnosed as such. Instead, the counselor he and Diane met with initially gave him two diagnoses: alcohol abuse and impulse control disorder. Michael was told that he needed to stop drinking and enroll in an angermanagement program. And though this may be objectively true—Michael may indeed have had did have a drinking problem, and his behavior at times was aggressive—this turned out not to be of much help in changing Michael’s behavior.

One reason why men like Michael are often misdiagnosed is because BPD typically manifests itself in different ways in men than it does in women. Here are a few examples of how BPD manifests itself in men:

Aggressively thin-skinned: On the few occasions when Diane tried to talk to Michael about any behavior on his part that bothered her—such as his drinking--he would fly into a rage and drive her away. Also, on these occasions he would sometimes accuse Diane of thinking she was “too good for him.” In other words, as insecure as he might be, Michael always took the offensive when he felt criticized.

Controlling through criticism: BPD men are more inclined to compensate for the lack of control they experienced as children by being overly controlling in their adult relationships. This often takes the form of being overly critical. For example, despite the fact that Diane had a full-time job just as he did, Michael was quick to criticize her if the house was messy or if dinner was not ready on time.

Irrational jealousy: Michael’s reaction after his and Diane’s night out with friends, along with his inclination to accuse her of being inappropriately “sexy” are good examples of this. It was, of course, Michael’s insecurity and his unconscious need to monopolize Diane’s attention that drove this behavior.

Possessive but detached: As much as Michael’s jealousy might be seen as possessiveness on his part, his role as a husband and parent was pretty much detached. He did not share much of his emotional life with Diane; and he showed relatively little interest in his children’s day to day lives.

Rejecting relationships: Over time Michael had turned sour on virtually every friendship he had. From Michael’s perspective, people were always falling short, always letting him down. He’d describe them as stupid, incompetent, or untrustworthy.

Holding grudges: “Michael can hold a grudge like you wouldn’t believe!” Diane said. He could talk about how his boss, a co-worker, or Diane had let him down even years after the fact. And even then Diane often failed to see the “offense” that

Using sex to relieve insecurity: Sex, for Michael, was not only an erotic experience, but something that temporarily quelled his free-floating anxiety and insecurity. As a result he often pressured Diane for sex at exactly the rimes when she was least interested in it—for example, when the stress in their relationship was high, of after he’d driven her away with his aggressive defensiveness.

Substance abuse: This is common in women with BPD as well, though women appear to be more vulnerable to abusing psychotropic medications, while men like Michael are inclined to drink or smoke pot. Michael drank as a means of anesthetizing the free-floating anxiety that had hung over him for his entire life.

When Michael accepted my suggestion that we meet individually for a while I was both surprised and pleased. In our first session he opened up and told me that he was, frankly, worried that his behavior and attitudes, if unchecked, could drive Diane away. Already he’d sensed some distance between them. He did not want to lose his marriage and family—so in his words he was “ready to talk.”

What this talking led to was my understanding of how Michael’s past had shaped his adult personality. His father had abandoned him and his mother when Michael was five. Michael never saw the man again. His mother, who was an alcoholic, subsequently married and eventually divorced another alcoholic, who was hostile and abusive to Michael. She’d had another son by her second husband, and this boy was the recipient of whatever largesse that man had been capable of. Moreover, though younger, Michael’s stepbrother had quickly learned that he could abuse Michael, if not physically then emotionally, by making sure he got almost all the attention and material benefits his parents had to give.

Michael’s mother, meanwhile, seemed to have decidedly divided loyalties. Sometimes, Michael said, she would defend him when she thought he was being treated unfairly; at other times she would stand back and do nothing. Similarly, she could be affectionate with Michael at times, but only when they were alone together. Most of the time, Michael felt ignored.

Michael had never spoken much to anyone about his childhood, including Diane. She knew only that Michael had had it “tough” as a child, but she had no real insight into what Michael had actually experienced. And she had never met his family, as Michael had broken contact with them well before they started dating.

A breakthrough came as a result of a very simple statement that Michael made in response to my asking his if he could give me an image of what it felt like for him, growing up in that family. At first he laughed, but then his expression turned sad. “It was like I was on the outside of that so-called ‘family’, looking in.”

I’ve heard this same description of their childhood so many times from men with BPD that I’ve come to see is as a template for working with them. To put it simply, through therapy they need to change their stance in life from “being on the outside looking in”, to “being on the inside, looking out.” In fact, I often refer back to this phrase when setting therapeutic goals and working on them

Recovering from Male BPD

Recovery for men like Michael is not so simple as sending them to an anger management class. It is in many ways as intense as treatment for women with BPD. But it must begin with both the therapist and the man with BPD realizing just what it is that are dealing with, and where its roots lay. The good news is that, with persistence and determination, men like Michael can recover from the emotional burdens that BPD places on them and those who love them.

@2014 by Joseph Nowinski

Joseph Nowinski, Ph.D. is a clinical psychologist and author of Hard to Love: Understanding and Overcoming Male Borderline Personality

I really appreciated reading this article and seeing how "Michael" was able to receive help for his underlying issues causing his poor behavior. Too many times behaviors represent other more entrenched psychological troubles. I also like the presentation of potential traits of those who might have BPD so they could possible seek help from a psychologist specializing in mens needs .

Alcoholics Anonymous seems to think that sobriety and working on their twelve steps will turn an alcoholic into a well-adjusted functioning human. More often than not, abstinence may exacerbate depression and bad behavior. People(men) use alcohol and drugs to counter the affects from other sources like BPD.

If one is involved in a relationship with an alcoholic that is thinking seriously about sobriety they need to be made woefully aware that not cessation of drinking may uncover a hotbed of other issues, issues that may or may not resolve themselves.

Borderline personality disorder is a heritable brain disease
Current Psychiatry 2014 April;13(4):19-20, 32.
Henry A. Nasrallah, MD
Editor-in-Chief
The prevailing view among many psy­chiatrists and mental health profession­als is that borderline personality disorder (BPD) is a “psychological” condition. BPD often is conceptualized as a behav­ioral consequence of childhood trauma; treatment approaches have emphasized intensive psychotherapeutic modali­ties, less so biologic interventions. You might not be aware that a large body of research over the past decade provides strong evidence that BPD is a neuro­biological illness—a finding that would drastically alter how the disorder should be conceptualized and managed.
Neuropathology underpins the personality disorder
Foremost, BPD must be regarded as a serious, disabling brain disorder, not simply an aberration of personality. In DSM-5, symptoms of BPD are listed as: feelings of abandonment; unstable and intense interpersonal relationships; un­stable sense of self; impulsivity; suicidal or self-mutilating behavior; affective in­stability (dysphoria, irritability, anxiety); chronic feelings of emptiness; intense anger episodes; and transient paranoid or dissociative symptoms. Clearly, these clusters of psychopathological and be­havioral symptoms reflect a pervasive brain disorder associated with abnormal neurobiology and neural circuitry that might, at times, stubbornly defy thera­peutic intervention.
No wonder that 42 published stud­ies report that, compared with healthy controls, people who have BPD display extensive cortical and subcortical abnor­malities in brain structure and function.1 These anomalous patterns have been detected across all 4 available neuroim­aging techniques.

Magnetic resonance imaging. MRI studies have revealed the following abnormalities in BPD:
• hypoplasia of the hippocampus, caudate, and dorsolateral prefrontal cortex
• variations in the CA1 region of the hippocampus and subiculum
• smaller-than-normal orbitofrontal cortex (by 24%, compared with healthy controls) and the mid-temporal and left cingulate gyrii (by 26%)
• larger-than-normal volume of the right inferior parietal cortex and the right parahippocampal gyrus
• loss of gray matter in the frontal, temporal, and parietal cortices
• an enlarged third cerebral ventricle
• in women, reduced size of the me­dial temporal lobe and amygdala
• in men, a decreased concentra­tion of gray matter in the anterior cingulate
• reversal of normal right-greater-than-left asymmetry of the orbitofron­tal cortex gray matter, reflecting loss of gray matter on the right side
• a lower concentration of gray mat­ter in the rostral/subgenual anterior cin­gulate cortex
• a smaller frontal lobe.
In an analysis of MRI studies,2 cor­relation was found between structural brain abnormalities and specific symp­toms of BPD, such as impulsivity, sui­cidality, and aggression. These findings might someday guide personalized in­terventions—for example, using neuro­stimulation techniques such as repetitive transcranial magnetic stimulation and deep brain stimulation—to modulate the activity of a given region of the brain (depending on which symptom is most prominent or disabling).

Magnetic resonance spectroscopy. In BPD, MRS studies reveal:
• compared with controls, a higher glutamate level in the anterior cingulate cortex
• reduced levels of N-acetyl aspar­tate (NAA; found in neurons) and cre­atinine in the left amygdala
• a reduction (on average, 19%) in the NAA concentration in the dorsolat­eral prefrontal cortex.
Functional magnetic resonance im­aging. From fMRI studies, there is evi­dence in BPD of:
• greater activation of the amygdala and prolonged return to baseline
• increased functional connectiv­ity in the left frontopolar cortex and left insula
• decreased connectivity in the left cuneus and left inferior parietal and the right middle temporal lobes
• marked frontal hypometabolism
• hypermetabolism in the motor cor­tex, medial and anterior cingulate, and occipital and temporal poles
• lower connectivity between the amygdala during a neutral stimulus
• higher connectivity between the amygdala during fear stimulus
• higher connectivity between the amygdala during fear stimulus
• deactivation of the opioid system in the left nucleus accumbens, hypothal­amus, and hippocampus
• hyperactivation of the left medial prefrontal cortex during social exclusion
• more mistakes made in differenti­ating an emotional and a neutral facial expression.

Diffusion tensor imaging. DTI white-matter integrity studies of BPD show:
• a bilateral decrease in fractional an­isotropy (FA) in frontal, uncinated, and occipitalfrontal fasciculi
• a decrease in FA in the genu and rostrum of the corpus callosum
• a decrease in inter-hemispheric connectivity between right and left ante­rior cigulate cortices.
Genetic Studies
There is substantial scientific evidence that BPD is highly heritable—a finding that suggests that brain abnormalities of this disorder are a consequence of genes involved in brain development (similar to what is known about schizophrenia, bipolar disorder, and autism).
A systematic review of the heritabil­ity of BPD examined 59 published stud­ies that were categorized into 12 family studies, 18 twin studies, 24 association studies, and 5 gene-environment inter­action studies.3 The authors concluded that BPD has a strong genetic compo­nent, although there also is evidence of gene-environment (G.E) interactions (ie, how nature and nurture influence each other).
The G.E interaction model appears to be consistent with the theory that ex­pression of plasticity genes is modified by childhood experiences and environ­ment, such as physical or sexual abuse. Some studies have found evidence of hypermethylation in BPD, which can ex­ert epigenetic effects. Childhood abuse might, therefore, disrupt certain neuro­plasticity genes, culminating in morpho­logical, neurochemical, metabolic, and white-matter aberrations—leading to pathological behavioral patterns identi­fied as BPD.

The neuropsychiatric basis of BPD must guide treatment
There is no such thing as a purely psycho­logical disorder: Invariably, it is an abnor­mality of brain circuits that disrupts normal development of emotions, thought, behavior, and social cognition. BPD is an exemplar of such neuropsychiatric illness, and treat­ment should support psychotherapeutic ap­proaches to mend the mind at the same time it moves aggressively to repair the brain.

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Thanks for this writing. I've been 10 years with a man who 'acts strange'. Well, it's been stormy. I started to do research and came to conclusion 4 years ago that he has BPD. At some point I had enough and left him. I said I come back on one conditition: he goes to therapy. I had gone alone to a couple therapist a few times, and finally he came with me. As the therapist was a nice person who 'understood his background' he thought it was a good idea, and came a few times. Then he started to say: see, therapist understands how my life is hart and it's all your fault ( in a nutshell). The therapist had told me he is clearly a narcisist, and I should just escape. But something was bothering me: he is clearly unhappy, desperate and sort of lost, regardless of somewhat narcistic behavior there's more to it.

I have became friends with a woman who started talk about her boyfriend and how 'nobody can imagine what it can be like' with him. Well, I could. It was like we were with identical twins. One day she texted me: ' I have came to conclusion that he has BPD'. At least I have one person who understands....

Hi! i would really need some advice... I've been with my boyfriend for 2 years and we struggle a lot and he has so much anger inside of him, depression, etc. i did a lot of research and i am pretty sure he's BPD... how can i approach him with this? I don't know what to do and i'm about to leave him because it's so hard on me and he doesn't see that...